Complaint
The co-complainants made a complaint regarding the services provided to their son, the consumer. The co-complainants made the following complaints:
- The general practitioner, a locum general practitioner, never advised that vomiting was a sign of meningitis;
- The general practitioner misdiagnosed the consumer's illness which led to his admission to the accident and emergency department of the public hospital;
- The general practitioner gave no guidelines to the consumer's parents as to what to do, should the consumer's condition deteriorate;
- There was a lack of communication between the general practitioner and the medical centre; and
- There was an absence of follow up care by the medical centre.
Investigation
The complaint was received by the Commissioner on 31 October 1997, and an investigation was undertaken. Information was obtained from the following people:
The Co-Complainant and Mother of the Consumer
The Co-Complainant and the Consumer's Father
The Provider/General Practitioner
The Consumer's General Practitioner/Medical Centre
The general practitioner's medical notes and the clinical records from the hospital about the consumer were obtained.
Independent professional advice was obtained by the Commissioner.
Information Gathered During Investigation
In late July 1997 the sixteen year old consumer became unwell having sore muscles, nausea, a red neck, shaking and a high temperature. His mother, one of the co-complainants, contacted the family's normal medical centre, between 8.00pm and 8.30pm. She spoke to a service that was contracted by the medical centre to provide after-hours services. It was arranged that a locum would do a house call. The locum sent was the general practitioner.
The general practitioner's clinical notes recorded that the consumer had a temperature of 39? and a pulse of around 100 beats per minute. During the consultation, the general practitioner saw the basin beside the consumer's bed and asked him if he felt sick. The consumer said he had felt nauseous before, but was all right at the moment. The general practitioner said that further examination revealed no specific cause for th nausea and the consumer was not abnormally drowsy. He said that there was no headache, no rash and no infected wounds. Nor were there any signs of internal infection in the chest or abdomen. Although the general practitioner stated that there was no neck stiffness or any signs of spinal rigidity and that Kernig's and Brudzinski's signs were negative, no comment was made on his notes at the time that he looked for these signs of meningism.
The general practitioner advised the Commissioner that he could not recall the exact words used by anyone, however, he did recall that the question of meningitis was discussed because of parental concern. He said that meningitis was not emphasised as there was insufficient evidence to justify such a diagnosis but he told them they should call the medical service back or take the consumer to hospital directly if anything untoward occurred. The complainants said that they were given no guidelines as to what to do should the consumer's condition deteriorate.
The general practitioner diagnosed influenza and prescribed panadol.
In early August 1997 at approximately 12.00pm the consumer was found unresponsive by his parents in his bed and an ambulance was called. The ambulance case report stated, amongst other things, that the consumer responded to pain, he was breathing shallowly, had a rash over his abdomen and shoulders and pain behind the eyes.
He was taken by ambulance to the accident and emergency department of a public hospital. The consumer was admitted to hospital with a headache, lethargy and a decreased level of consciousness, as well as a classical meningococcal-type petechiael rash. The accident and emergency department recorded a tentative diagnosis of meningitis. He was intubated and ventilated and taken to the department of critical care on the same day. It was noted that in his past history the consumer had had a single grand mal seizure one month prior to his admission. He was later transferred to the infectious diseases unit.
A computerised tomography ("CT") scan of the consumer's head showed meningeal enhancement consistent with meningitis. A diagnosis of presumed meningococcal meningitis was made, but a lumber puncture was not performed.
The consumer has since recovered.
On the evening of the day the consumer was taken to hospital the complainants were contacted by the medical service following up from the general practitioner's visit. The medical service was informed that the consumer had meningitis and was in critical care in hospital.
The consumer's general practitioner at the medical centre, stated to the Commissioner that he had received a letter from the medical service which indicated that a visit had been made by a locum but did not mention the later admission to hospital. The general practitioner said that this kind of information is not generally passed on to the family general practitioner because it is second hand information which "usually leads rapidly to corruption of the message". He also said that the consumer's general practitioner would be informed by the hospital in due course.
The consumer's general practitioner received a clinical summary note from the hospital dated six days after the consumer had been taken to hospital which indicated that the consumer had been discharged. He received two further letters dated ten days and nineteen days after the consumer had been taken to hospital from the hospital. The first letter set out the consumer's symptoms, the presumed diagnosis of meningococcal meningitis and the treatment he had received in hospital. It also said that the consumer had some residual ringing in his ears and so he would be seen in the hospital clinic in two weeks time. The later letter stated that the consumer had been seen in the clinic for review. It was reported that the ringing in the consumer's ears had settled down and he had no problems apart from tiredness since discharge.
The consumer's general practitioner said that none of this information indicated anything other than an uneventful recovery. In particular, he said there was no mention of the stressful circumstances surrounding the consumer's admission to hospital, nor any suggestion that follow up by the general practitioner was appropriate.
Upon receiving a letter of complaint from the co-complainants in relation to this matter, the consumer's general practitioner telephoned the consumer's father. The consumer's general practitioner informed the Commissioner that he explained that his usual practice following discharge of patients from hospital "is to undertake follow up only when the necessity for such action is advised by the hospital doctors." The consumer's general practitioner said he would draw the consumer's father's concerns to the attention of the management of the medical service and the general practitioner. He also said he suggested that the consumer's father contact the Health and Disability Commissioner's Office. The consumer's general practitioner reported to the Commissioner that the matter was satisfactorily resolved between himself and the consumer's father at the end of the conversation. The consumer's father acknowledged having that conversation with the consumer's general practitioner but disagreed with the consumer's general practitioner's comment that the matter was satisfactorily resolved.
The consumer's general practitioner said that he spoke to the chairman of the board of directors of the medical service and advised him of the situation. He said that the chairman asked him not to speak to the general practitioner as that was his responsibility, which he would undertake.
The Commissioner obtained professional advice in relation to the general practitioner's conduct. It was noted that there was clearly some difference of opinion between the letter of complaint and the general practitioner's reply regarding whether or not the question of meningitis was raised and discussed in any substantial form.
The general practitioner, in a letter dated mid-October 1997, stated, "[t]here is no way to distinguish meningococcal meningitis from any other acute systemic infection before the characteristic signs eventuate."
The independent expert advised the Commissioner as follows:
1) "I do not believe that [the consumer's] symptoms at the time were indicative of meningitis. Meningitis was certainly a possibility but by far the most likely diagnosis was that of a viral influenza which would have explained very adequately all the symptoms at the time.
2) The treatment options were only conservative, namely bed rest, fluids and paracetamol to reduce fever. I believe [the general practitioner] did make an appropriate choice of treatment given the most likely diagnosis.
3) I do not believe that [the consumer's] previous seizures had any influence at all on the likelihood or otherwise of his developing meningitis.
4) ?here is simply no way of making that diagnosis when you see someone in the early stages of the illness?
The Code of Health and Disability Services Consumers' Rights
RIGHT 4
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical and other relevant standards.
5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
Clause Three - Provider Compliance
1) A provider is not in breach of this Code if the provider has taken reasonable actions in the circumstances to give effect to the rights, and comply with the duties, in this Code.
2) The onus is on the provider to prove that it took reasonable actions.
...
Opinion: No Breach - The General Practitioner
In my opinion the general practitioner did not breach Right 4(2) and Right 4(5) of the Code of Health and Disability Services Consumers' Rights as follows:
Right 4(2)
While the general practitioner failed to recognise the consumer's meningitis, there is no evidence that the consumer's symptoms at the time were indicative of meningitis. Meningitis was certainly a possibility, which the general practitioner appeared to turn his mind to, but the consumer's symptoms were also consistent with viral influenza which he diagnosed. Since influenza was the most likely diagnosis the treatment prescribed was appropriate. In the circumstances and given the symptoms at the time, in my opinion the general practitioner's failure to make the diagnosis of meningitis was reasonable.
Right 4(5)
While the general practitioner did not inform the medical centre of the consumer's admission to hospital, he did not find out about the consumer's admission directly. The general practitioner also knew that the hospital was responsible for informing the consumer's general practitioner. In my opinion the general practitioner's conduct was reasonable in the circumstances.
Opinion: No Breach - The Consumer's General Practitioner
In my opinion, the consumer's general practitioner did not breach Right 4(5) of the Code of Health and Disability Services Consumers' Rights.
The letters from the hospital showed the hospital was attending to the consumer's follow up care and that he was successfully recovering from meningitis. On this basis the consumer's general practitioner took the reasonable view that no follow up by him was necessary. When he received the letter of complaint the consumer's general practitioner contacted the consumer's father in an attempt to resolve the complaint.
Actions:
The General Practitioner
In future it would be prudent for the general practitioner to clearly state to the consumer, or the consumer's parents, that the examination performed does not exclude the possibility of early meningitis and that if the patient deteriorates in any way help should be sought.
The Consumer's General Practitioner
I draw the consumer's general practitioner's attention to Right 10 of the Code of Health and Disability Services Consumer's Rights. This requires providers of healthcare services to, amongst other things, have a complaints procedure which deals with complaints by consumers in accordance with the Code.
The Medical Service
I recommend the medical service review its policy of handling emergency calls to ensure all information is sent on to the consumer's general practitioner to ensure a full medical history is available on the consumer's file.
For further information, contact: HDC Communications Section (09) 373 1060.